Free 09101.PDF - Indiana

APPLICATION FOR CERTIFICATION OF ENGINEERING INTERN
State Form 9101 (R6 / 4-02) Approved by State Board of Accounts, 2002

FOR OFFICE USE ONLY CN OU NM TB RE OR L

DO NOT WRITE IN THIS SPACE (Incomplete applications will not be accepted.)
Application number Date received Certification number Date received

This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purpose of this board under I.C. 25-31. Disclosure of this information is mandatory. Incomplete applications are subject to denial by the board. Upon completion, this form will be treated as a public record. * Your social security number is requested by this agency in accordance with I. C. 4-1-8.1, disclosure is mandatory; this record cannot be processed without it.

SENIORS enrolled in an ABET engineering curriculum shall complete sections 1,2,4 & 6 only. Other applicants shall complete sections 1 through 6. INSTRUCTIONS: Please type or print in ink. If necessary, attach extra sheets with each dated and signed. This application must be accompanied by a photo. Enclose an examination and enrollment fee of $100.00 (One-Hundred dollars), payable to Engineer's Registration Board. Return application and all accompanying documents to: Indiana Professional Licensing Agency Indiana Government Center South 302 W. Washington Street, Room 034 Indianapolis, IN 46204 Designate preferred mailing address by placing an "x" in the appropriate box. 1
Name of applicant (first, mi, last)

APPLICANT INFORMATION
Have you ever had a name change? * Social Security number

Yes
Birth place

No
Birth date

Address (number and street)

City, state, ZIP code

Home telephone number

(
Name of firm

)

Address (number and street)

Business telephone number

(
City, state, ZIP code

)

2

COLLEGE INFORMATION (Attach certified copy of transcripts from each school attended.) DATES ATTENDED ADDRESS OF INSTITUTION (City, state, ZIP code) NAME OF INSTITUTION From To

GRADUATION Degree Date

Reference forms are attached from 3 persons listed below. References should have personal knowledge of your experience and/or ability to qualify. Providing references with up-to-date personal information will enable objective, confidential evaluations by the board. DO NOT submit the name of an Indiana board member as a reference. 3 NAME OF REFERENCE (Minimum of 3 required) REFERENCE PE NUMBER REFERENCES ACQUAINTANCE, EMPLOYER, ASSOCIATE, ETC. CURRENT ADDRESS (Number and street, city, state, ZIP code)

4

PERSONAL BACKGROUND Yes Yes Yes (Continued on the reverse side) No No No

Have you ever been denied certification or has a certificate ever been revoked/suspended?

Have you been convicted of: (A) an act which would constitute a ground for disciplinary sanction under I.C. 25-31 or (B) a felony that has a direct bearing on your ability to practice competently? Have you previously applied for and or taken the EI examination in Indiana or any other state? If yes, please attach a statement identifying dates, states and any other pertinent information.

INSTRUCTIONS: A photo must be attached to this application. List all engineering experience positions, beginning with the most recent. If necessary, attach extra sheets following the prescribed format. Please sign and date any extra sheets. For part-time employment, if less than 40 hours per week, list number of hours in space provided below. 5
Name of current employer

EXPERIENCE
Job title No. of years employed Name of supervisor Period of employment

From___________ To __________
Address (number and street)

Full-time Part-time

No. of hours employed

Full-time Part-time

City, state, ZIP code

Duties

Name of current employer

Job title No. of years employed Name of supervisor

Period of employment

From___________ To __________
Address (number and street)

Full-time Part-time

No. of hours employed

Full-time Part-time

City, state, ZIP code

Duties

Name of current employer

Job title

Period of employment

From___________ To __________
Address (number and street) No. of years employed Name of supervisor

Full-time Part-time

No. of hours employed

Full-time Part-time

City, state, ZIP code

Duties

6

NOTARY CERTIFICATE STATE OF COUNTY OF On ____________________ day of ___________________ , 20 ______ , I, ________________________________________________________ , a resident of __________________________ certify that I have read the text of the Indiana Registration Act for Professional Engineers as amended, covering the requirements to be met by an applicant, and Rules of the board, that the statements contained in this application are true and correct to the best of my knowledge and that if granted registration I will abide by the Indiana Registration Act and Rules of the board. I authorize those whom I have given as references, whether they may be an individual, a company, or an institution, to furnish the State Board information concerning my education, experience, character and suitability for practicing Engineering. I agree to release and hold harmless any individual, company, or institution and any person or persons connected therewith from liability imposed by law in furnishing such information.

}

SS:

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to (Notary Public)

County of residence